Form guide · WH-380-F

How to fill out Form WH-380-F (FMLA, family member)

WH-380-F is the Department of Labor's form for certifying that a family member's serious health condition needs the employee's care. Your patient is the family member. This guide walks through your part, Section III, in the form's order.

Form: Certification of Health Care Provider for Family Member's Serious Health Condition (FMLA)
Issued by: U.S. Department of Labor, Wage and Hour Division
Revision: Revised June 2020 (OMB 1235-0003, expires 8/31/2029)
Checked against the source: November 5, 2026

What it is and when it is used

Under the FMLA, an employee may take leave to care for a spouse, a parent, a child under 18, or an adult child who cannot care for themselves because of a disability, when that family member has a serious health condition. The employer may ask for a medical certification from the health care provider of the family member who needs care. WH-380-F is the form the Department of Labor publishes for that certification, and the form says using it is optional.

The form defines a serious health condition as one that involves inpatient care or continuing treatment by a health care provider, and lists each category on its last page.

When the employee needs leave for their own condition, the form is WH-380-E.

Who completes which part

Part	Completed by	What it covers
Section I	Employee or employer	The employee's and employer's names, the date the certification was requested and the date it is due.
Section II	Employee	The family member's name and relationship, the care the employee will give, the leave and any reduced schedule needed, and the employee's signature. The form asks the employee to do this before handing the form to you.
Section III	Patient's health care provider	Your contact details, Part A (medical information), Part B (amount of leave needed), then your signature and the date.

The provider's part, section by section

In Section III, "the patient" is the family member you treat, not the employee. The form asks for your best estimate, based on your knowledge, experience and examination of the patient.

Your contact details

Your printed name, business address, type of practice or specialty, phone, fax and email.

Part A: medical information

Item 1 is the patient's name. Item 2 asks for the approximate date the condition started or will start, and item 3 how long it lasted or will last.

Item 4 asks you to describe the care the patient needs. The form says care must be medically necessary for the FMLA to apply, and gives examples such as help with basic medical, hygiene, nutrition or safety needs, transportation, physical care, or psychological comfort.

Item 5 is the same set of boxes as on WH-380-E. Check every one that applies, because each checked box needs an amount of leave in Part B:

Inpatient care, with the dates.
Incapacity for more than three consecutive full calendar days, with the dates, visit dates, and whether there is continuing treatment.
Pregnancy, with the expected delivery date.
Chronic condition that needs treatment visits at least twice a year.
Permanent or long term condition that needs continuing supervision.
Condition that needs multiple treatments.
None of the above. The form says no more information is needed; go to the signature.

Item 6: other medical facts

If needed, briefly describe other relevant medical facts. The form says you may, but do not have to, give symptoms, the diagnosis or the treatment, and that some state or local laws may not allow you to disclose them. Do not include genetic test results or a family history of disease.

Part B: amount of leave needed

Answer each item that matches a box you checked in Part A. The form warns that words like "lifetime" or "unknown" may not be enough, so give a specific estimate.

Item 7: dates of the patient's planned treatment, such as scheduled visits.
Item 8: referrals to other providers, what the treatment is, its start and end dates, and how long it takes including recovery.
Item 9: a continuous period of incapacity, with its start and end dates.
Item 10: whether the employee needs to be away from work now and then to care for the patient, for example during flare-ups, with how often episodes are likely over the next six months and how long each one lasts.

Signature

Sign and date the form at the end of Part B. WH-380-F has no Part C.

Deadlines the form states

The form says the employer must allow at least 15 calendar days to return the certification, and that the employee is responsible for getting it back on time. The due date is written in Section I, item 3.

Where it goes

The form says not to send it to the Department of Labor. Return it to the patient or the employee, who gives it to the employer.

Official source

Revised June 2020 (OMB 1235-0003, expires 8/31/2029). Checked against the issuer's copy on November 5, 2026. This guide paraphrases the form's own instructions; the form and U.S. Department of Labor, Wage and Hour Division are the authority.

How Scribeable fills it

Scribeable fills the official WH-380-F from your visit note. It writes an answer only when the note states it.

Anything the note does not say stays blank for you to complete. Sections I and II are left for the employer and the employee. Your signature and the date you sign are always yours to add.

Each filled answer shows the sentence in the note it came from, so you can check it before you sign.

You review every field, then download or print the form, sign it, and give it to the patient or the employee.

Other forms

Forms from the visit note

Write the note once. Fill the form from it.

14 days of full Pro. No sales call.

Start free trial All forms

14-day Pro trial, no credit card required. Everything in Pro, including Rounding, for up to 150 notes. To keep Pro after day 14, subscribe for $79/month plus applicable tax. If you don't, nothing is charged and your account moves to the Free plan once you add your NPI (until then it is read-only), with every note kept.